A cross-sectional study on the self-management of asthma and asthma control among adult asthmatic patients in the Aseer region, KSA

Proper management of asthma is crucial for maintaining control over the disease and has a significant impact on the patient’s overall condition. The purpose of this study was to determine the extent of self-management and the level of Asthma control in the patients from the Aseer region of Saudi Arabia, as well as to investigate determinants of illness control. A study was conducted using quantitative cross-sectional methods. Researchers utilised a web-based, self-administered structured questionnaire to gather data. The questionnaire included three sections: a socio-demographic section, an Asthma Self-Management Questionnaire (ASMQ), and Asthma Control Test (ACT). An analysis using the chi-square test was conducted to determine if there was a notable connection between the socio-demographic characteristics of the participants and the level of asthma control. A total of 305 responses were collected. The average score for the Asthma Self-Management Questionnaire was 5.72, which corresponds to 40.9%. Based on the scores from the Asthma Control Test, it was found that 60 patients (20.0%) had asthma that was not under control, 94 (30.0%) had asthma that was partially controlled, and 151 (50.0%) had asthma that was well controlled. Factors such as gender, non-smoking status, and having asthma for over 10 years (p ˂0.05) were found to be strongly correlated with improved disease control. Significant gaps were found in patients’ awareness of the most important and critical aspects concerning the condition, medications, and preventative actions that limit asthma aggravation. To address the current situation, hospitals and clinics must make substantial efforts.

Asthma is a chronic respiratory condition characterized by airway inflammation and hyperreactivity.Effective self-management is crucial for maintaining control and reducing the frequency and severity of asthma attacks.Various studies and literature have explored the relationship between self-management practices and asthma control 1,2 .An asthma diagnosis is confirmed with spirometry and pulmonary function test, where spirometry, which measures how much air a patient can expel in one forced breath, is a noninvasive test used for diagnosing and monitoring a variety of lung disorders 3,4 .Many factors may trigger asthma, such as weather changes, seasonal allergies, air pollution, smoking, medication like aspirin, highlands, pets, genetics, Dust, perfumes, and cosmetics.In addition, commodities that may affect the severity of asthma include infections, allergies, obesity, anxiety, stress, depression, and obstructive sleep apnea 5,6 .In Saudi Arabia, more than 2 million are diagnosed with asthma, and 10.6% of asthmatic patients use medications to control the symptoms 7 .Many studies show the prevalence of uncontrolled asthma patients in Saudi Arabia is about 77.0% in females and 58.9% in males.

Sample size calculation
The Raosoft program was used to estimate the sample size using a margin of error of 5% and a 95% confidence interval 12 .The estimated final sample size calculated was 305.377 patients were approached but only 305 patients responded, remaining were not willing to participate, the total population used to calculate the sample size was 20,000.

Data collection and statistical analysis
Before completing the questionnaire, the participants could introduce themselves and learn more about the study's purpose.The participants were assured that their responses would be kept anonymous for a valid response.
The tool used for data collection was a web-based structured knowledge questionnaire comprised of multiplechoice questions.The purpose of the study was clearly stated in the questionnaire.The questionnaire consists of three main parts: the first includes demographic variables, the second contains questions regarding responses to the Asthma Control Test, and the third part focuses on asthma Self-management knowledge.Each response was given a score of one, and all the scores were summed to get a raw score that ranged from 0 to 16.Then, the raw score was transformed to a scale of 0 to 100, and the final score was reported.A higher score represented participants with more excellent knowledge of self-management of asthma.A total of 305 individuals completed the questionnaire and were included in the current study.
A Statistical Package for Social Sciences version 20 (SPSS Inc., Chicago, IL, USA) was used to analyze the data (SPSS).Two expert statisticians did the analysis.Descriptive and inferential statistics were used for the data analysis.The p-value of less than 0.05 was considered significant.

Ethical approval
Ethical approval for this study was obtained from the "Ethical Committee of King Khalid University, Ethical approval NO: ECM#2021-5910".This study complies with the Declaration of Helsinki and was performed after obtaining ethics committee approval.An informed consent form was available on the first page of the questionnaire, stating that participation is voluntary, that confidentiality is guaranteed, and that all information will be used solely for research reasons.

Demographic characteristics of participants
In total, 305 patients were included, with 167 (55%) females.Most patients in the community were between the ages of 45 and 60. 90% of patients reported attending formal asthma education programs.Table 1 displays socio-demographic information about research participants.

Responses and total score to Asthma Self-Management Questionnaire
The mean score for (ASMQ) was 40.9%.Table 2 demonstrates the patients' correct responses to the self-management Questionnaire.Overall, 72% of patients answered that they should hold their breath after taking the dose, which means they could follow instructions on how to use their inhalers.However, a lower percentage was observed when patients were asked about the knowledge that exercise helps improve breathing capacity.

Asthma control
The Response to the Asthma Control Test is shown in Table 3.According to the scores, 60 patients (20.0%) had uncontrolled asthma, 94 (30.0%) had partially controlled asthma, and 151 (50.0%) had controlled asthma.

Predictors of asthma control
The results showed that regardless of gender, non-smoker, and more than 10 years duration of asthma (P ˂ 0.05), these variables were highly associated with better disease control, as described in Table 4.

Discussion
Asthma is a chronic respiratory condition characterized by airway inflammation and hyperreactivity.Effective self-management is crucial for maintaining control and reducing the frequency and severity of asthma attacks.The current study's demographic data revealed that more than half of the patients recruited were females.According to the Nicolai et al. cohort's study, males are likelier than females to suffer from asthma; however, the gender ratio is reversed in adults.It is unclear when this transformation occurs or by what mechanism 13 .Most patients in this study were between 45 and 60.
Asthma in the elderly might be challenging to diagnose due to changes in clinical and functional characteristics 14 elderly experience daytime symptoms, associated with a poor prognosis leading to an eventual loss of functions 15 patients aged between 45-60 years old live in town In low-and middle-income countries (LMICs), urbanization has been linked to temporal and geographical changes in asthma prevalence.However, little is known about the mechanisms that link urbanization with asthma, which may be explained by the empirical approaches employed to evaluate the urbanization-asthma relationship 16,17 , the recruited patients live in a high-altitude area that might contribute to the occurrence and the worsening of the patient's symptoms.Similar studies were conducted and had similar findings 18 a meager percentage of the recruited patients were actively smoking, and a higher percentage of patients were non-smokers.In recent studies, tobacco smoking has been linked to more severe asthma symptoms, a faster deterioration in lung function, and worse responses to corticosteroids 19 .This study also agrees with a recent study conducted in Saudi Arabia, which indicated a Vol:.(1234567890  decrease in the quality of life of asthmatic male patients who used daily smoking and women who had a household member who smoked inside the house 20 .
In general, recruited patient responses to the Asthma Self-Management Questionnaire uncovered significant gaps in patients' knowledge about asthma and poor understanding of the treatment and the approaches for preventing asthma attacks.The main evident issue was the poor inhaler technique knowledge on how to use the inhaler, as the patient failed to repeat simple usage instructions.The current study sheds light on the poor disease control caused by a lack of healthcare training and counselling during patient appointments/visits.This outcome has been, however, observed in several studies 21,22 .
Most patients did not know the difference between the medications that should be used to relieve the symptoms of acute asthma attacks and long-term maintenance therapy.Also, most patients did not know they would require maintenance medicines if they were using short-acting reliever medications.The final result of poor patient understanding of their disease state and knowledge of the treatment options directly impacted the absolute compliance to therapy 23 Almost 35% of patients in the current study demonstrated good knowledge regarding the role of flu vaccination in reducing the occurrence of asthma flare-ups; many studies reported a correlation between viral infections and asthma exacerbation 24,25 .However, only 28% of patients knew that asthma is not a curable disease; a lack of knowledge of this fact might have contributed to the poor compliance as many patients stop their medication once the asthma attack has subsided or if they don't suffer from symptoms.A fascinating finding noted in this study is that approximately 50% of the patients considered that their disease was controlled or partially controlled during the previous four weeks.This finding proves that patients are under the impression that their condition is under control and that it is all attributed to a lack of knowledge to correlate symptoms with poor control.
Various studies and literature have explored the relationship between self-management practices and asthma control.A study published by NCBI found that higher levels of asthma control (measured by ACT or GINA criteria) correlated with better self-management knowledge (measured by ASMQ scores).Patients with better self-management knowledge had better asthma control.It was noted that the level of knowledge on asthma selfmanagement was generally low among patients.This lack of knowledge significantly affected their level of asthma control 26 .A study published in Nature discussed various barriers and facilitators to effective self-management in asthma.Despite being an established method for controlling asthma, the promotion, uptake, and use of selfmanagement practices vary widely 27 .Research from the Journal of Managed Care & Specialty Pharmacy (JMCP) showed that patients who received self-management support services from community pharmacists had better symptom control and lower severity 28 .A randomized controlled trial published in the Health Education Research journal concluded that an asthma self-management model significantly improved the quality of life for asthma patients, further emphasizing the importance of self-management in asthma control 29 .
Self-management education, which includes personalized action plans, has been shown to significantly improve asthma control.According to a Cochrane review, self-management education that includes a written action plan and regular medical review is associated with reduced hospitalizations, emergency room visits, and days off work or school due to asthma 30 .Empowering patients through education and training enables them to recognize and manage symptoms, use medications appropriately, and avoid triggers.This empowerment leads to improved asthma outcomes.For example, a study by Gibson et al. demonstrated that patients who received self-management education had better asthma control and quality of life compared to those who received usual care 30 .Adherence to prescribed medication regimens, especially inhaled corticosteroids, is a cornerstone of asthma self-management.Studies have shown that poor adherence is a major factor contributing to poor asthma control.A study by Bender et al. found that patients with higher adherence to controller medications had better asthma control and fewer exacerbations 31 .The development of mobile health applications has opened new opportunities for asthma self-management.mHealth apps can include prescription reminders, symptom tracking, and instructional resources.Marcano Belisario et al. conducted a systematic study that emphasised the potential of mHealth interventions to improve medication adherence and asthma control 32 .Telemedicine has emerged as an effective asthma care method, especially during the COVID-19 pandemic.Virtual consultations enable continual monitoring and support, which can improve self-management habits.Studies have demonstrated that telemedicine can enhance asthma control and patient satisfaction 33 .
This study has its own limitations.The sample size is small so the study cannot be generalized.While this study investigated asthma control and self-management, it has numerous limitations due to the lack of precise data on some variables.The severity of asthma in individuals was not specifically specified, which may restrict the generalizability of our findings to diverse asthma phenotypes and illness severities.Additionally, patients' allergy status, including allergen sensitivities, para-clinical findings like skin test results and spirometry readings prevented a complete knowledge of asthma control's physiological and immunological aspects.Our results may be limited by the absence of these critical variables, highlighting the need for future research to assess asthma severity, allergic status, and para-clinical findings to better understand their effects on asthma control and management as well as to estimate the association between self-management and asthma control.

Conclusion and recommendations
Significant gaps were found in patients' awareness of the most important and critical aspects concerning the condition, medications, and preventative actions that limit asthma aggravation.To address the current situation, hospitals and clinics must make substantial efforts.Effective self-management is critical to maintaining optimal asthma control.The results showed that regardless of gender, non-smoker, and more than 10 years duration of asthma, these variables were highly associated with better disease control.
Education, medication adherence, regular monitoring, and personalized action plans are all important factors that lead to better outcomes.Addressing hurdles such as health literacy and socioeconomic status, as well as utilizing technology, can help to improve self-management behaviors.Continued research and personalized interventions are required to help patients effectively manage their asthma.

Table 3 .
Response to the asthma control test.N, frequency; %, percentage.